Our major hypothesis is that distinct practice patterns for patients with RA are identifiable, and involve differing combinations of primary and specialty care, and that these patterns are associated with significant differences in process of care quality, outcomes, and utilization of services. Primary care physicians and rheumatologists currently are thought to have substantially different approaches to evaluation and treatment of patients with rheumatoid arthritis (RA). These differences are further accentuated by the growth of managed care, with increased emphasis on the primary care physician. There has been now and growing interest in research regarding appropriate roles for primary care and specialist physicians and how alternative patterns and structures for primary and specialty patient care and referral affect patient care quality and outcomes, effectiveness, and efficiency. In this project, we will analyze the prevailing management and referral patterns for patients with RA in three large managed health-care systems. We will measure and compare the quality, appropriateness, and outcomes of care among the major patterns of care, identify factors determining which patients are assigned to each of the specific patterns(e.g., patient characteristics, physician training, provider organization policies and incentives), and derive practice implications and develop clinical recommendations regarding optimal management and referral for patients with RA. The four-year study will examine practice patterns and their outcomes for 400-500 patients in three managed care settings in Southern California, using computerized encounter, scheduling, pharmacy and laboratory data; systematic abstraction of medical records; and through patient surveys.